Event
- Event ID
- 1032
- Quality
- Description
- In a refinery, a fire occurred at a new reactor for the vacuum distillate hydro-desulphurisation unit. Process gas (hydrogen, hydrocarbon, etc.) blew from a flange of upper piping in the reactor. It ignited producing 0.5-2 meters high flames. The reason for the leak was a lack of tightness of the flange.
Emergency stop of th plant was executed, thereactor was cooled and purged with nitrogen. The fire department was alarmed. - Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- Fire (No additional details provided)
- Macro-region
- Asia
- Country
- Japan
- Date
- Main component involved?
- Flange
- How was it involved?
- Leak & Formation Of A Flammable H2-Air Mixture
- Initiating cause
- Loss Of Tightness (Wrong Operation)
- Root causes
- Root CAUSE analysis
- The INITIATING CAUSE was considered a loose high-pressure flange due to uneven tightening force, on uneven thermal expansion of materials at a temperature of 390 °C.
The tightening operation of hot bolting at start-up three months before was inadequate.
The ROOT CAUSE was a shortcoming in the procedure for hot-bolting, tohether with a lack of effective regular inspection. There was also a alck of management actions, becasue the difficulty of hot-bolting was known and several otehr plants were able to prevent occurrence of these events.
Facility
- Application
- Petrochemical Industry
- Sub-application
- Hydrodesulphurisation process
- Hydrogen supply chain stage
- All components affected
- highpresure, high tmeprature flange
- Location type
- Open
- Location description
- Industrial Area
- Operational condition
- Pre-event occurrences
- The reactor was new, but the operation was a standard operation.
Emergency & Consequences
- Number of injured persons
- 0
- Number of fatalities
- 0
- Environmental damage
- N
- Property loss (onsite)
- Y
- Property loss (offsite)
- N
- Post-event summary
- Heat damage and some of vacuum distillate oil was lost.
Lesson Learnt
- Lesson Learnt
- It is well-known that to manage the tightening of flanges in high-temperature and high-pressure sections, a quantitative control of the tightening force is required. Critical as well is to determine the number of times this control should be performed, and at which moments of the pressure-temperature history of the flange.
Since not all flanges in complex high-pressure high-temperature systems are experiencing the same conditions, the hot bolting procedure should be based on the most severe conditions.
The investigation found out that:
1. There was not a sufficient margin for tightening force on hot-bolting.
2. The upper part and the lower part of the flange were different (respectively SUS321 steel and 2-1/4Cr-1Mo steel with an overlay). Therefore, their coefficients of thermal expansion differed.
3. The thermal expansion of the piping acted in the direction of opening the flange.
Findings 2 and 3 were specific to this flange only. It is possible that the special combinations of different materials, geometric configuration and harsh working conditions may have been overlooked during the design phase and/or during operation. - Corrective Measures
- Based on the lessons learnt, the following was implemented:
(1) The procedures for hot-bolting were reviewed and the management system for bolt-tightening force was strengthened. To achieve an effective tightening able to withstand the harsh conditions experienced by the flange, hot-bolting shall be done every 30 °C, above the temperature of 360 °C.
(2) A dedicated check team was set up for the flange of a high-temperature and high-pressure part of newly constructed piping and vessels. This team carried out periodic inspections.
Event Nature
- Release type
- gas mixture
- Involved substances (% vol)
- H2,
hydrocarbons - Actual pressure (MPa)
- 10
- Design pressure (MPa)
- 10
- Presumed ignition source
- Not reported
References
- Reference & weblink
Orignal source lost. RISCAD is closed, now in database shippai:<br />
https://www.shippai.org/fkd/include/fkd_showCase.php?id=CC0000200&text1… />
(accessed April 2025)Event no. 1989-059 of the KHK (High Pressure Gas Safety Association): <br />
https://www.khk.or.jp/public_information/incident_investigation/hpg_inc… />
(accessed May 2025)
JRC assessment
- Sources categories
- JST